Lia Willebrand, L.Ac.
Informed Consent to Treatment
By signing below, I do hereby voluntarily consent to be treated with acupuncture and/or substances from the
Oriental Materia Medica by Lia Willebrand, L.Ac. I understand that methods of treatment may include, but are not
limited to, acupuncture, moxibustion, cupping, electrical stimulation, massage, herbal medicine, supplements, and
nutritional counseling.
I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side
effects. These side effects could include, but are not limited to: local bruising, minor bleeding, fainting, pain or
discomfort, numbness or tingling near the needle site, and the possible aggravation of symptoms existing prior to
acupuncture treatment. Bruising is a common side effect of cupping. Unusual risks of acupuncture include
spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is
another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe
environment. Burns and/or scarring are a potential risk of moxibustion and cupping.
The herbs and nutritional supplements (which are from plant, animal and mineral sources) that have been
recommended are traditionally considered safe in the practice of Oriental Medicine, although some may be toxic in
large doses. I understand that I am not required to take these substances but must follow the directions for
administration and dosage (provided both orally and in writing) if I do decide to take them. The herbs may have an
unpleasant taste or smell. I am aware that certain adverse side effect may result from taking these substances.
These could include, but are not limited to: nausea, gas, changes in bowel movement, abdominal pain or
discomfort, vomiting, headache, rashes, hives, tingling of the tongue, and the possible aggravation of symptoms
existing prior to herbal treatment. Should I experience any unanticipated or unpleasant effects which I associate
with these substances, I should suspend taking them and call Lia Willebrand, L.Ac. as soon as possible.
I understand that I may also be given acupressure/tui-na massage as part of my treatment to modify or prevent pain
perception and to normalize the body’s physiological functions. I am aware that certain adverse side effects may
result from this treatment. These could include, but are not limited to: bruising, sore muscles or aches, and the
possible aggravation of symptoms existing prior to treatment. I understand that I may stop the treatment if it is too
uncomfortable.
I understand that some acupuncture or massage procedures may be inappropriate during pregnancy. I understand
that some herbs may be inappropriate during pregnancy and breast-feeding. I will notify Lia Willebrand, L.Ac. if
I am or become pregnant or am or will begin breast-feeding.
I understand that while this document describes major risks of treatment, other side effects and risks may occur. I
do not expect Lia Willebrand, L.Ac. to be able to anticipate and explain all possible risks and complications of
treatment, and I wish to rely on my practitioner to exercise judgment during the course of the treatment which she
thinks at the time, based upon the facts then known, is in my best interest.
I understand Lia Willebrand, L.Ac. may review my patient records and lab reports, but all my records will be kept
confidential and will not be released without my written consent.
By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment. I
have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask
questions. I intend this consent form to cover the entire course of treatment for my present condition and for any
future condition(s) for which I seek treatment.
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